O.T.R.A. ROADSIDE SERVICES, INC.
New Customer Questionnaire
Company Name:
*
First Name:
*
Last Name:
Phone:
*
Email:
New Unit Questionnaire
What type of chassis is this unit:
*
Select Unit Type
Pick-Up Truck
Tractor
Trailer
VIN:
Year:
Make:
Model:
Unit Number:
Unit Nickname:
License Plate:
Service Request Questionnaire
Complaints / Problems / Requests
Describe first complaint, problem, or request:
*
How urgent is this:
*
Schedule as soon as possible
Schedule repair today
Emergency - Get this fixed right away
Remember for the next visit
Add another
Scheduling & Authorization
When will the unit be available for repairs:
Now
The unit MUST be accessed at the above date and time.
When would you like the unit back:
Return ASAP
How would you like us to access the unit:
*
Select Access Method
No preference, just get it done!
Customer will bring unit to the shop
Shop will service unit on-site
Shop will pick up unit and bring to the shop
Shop will tow unit
Where will this unit be located for access:
*
Select Address
Temporary Address (please put address in the Helpful Notes below)
Add A New Address
Address Name:
*
Street Address:
*
City:
*
Country:
*
United States
Canada
Dominican Republic
State:
*
Postal Code:
*
Save
Cancel
Would you like the shop to deliver the unit:
*
No - Customer will pick up unit from shop
Yes - Shop will return unit to customer
Where would you like this unit delivered:
*
Select Address
Temporary Address (please put address in the Helpful Notes below)
Add A New Address
Address Name:
*
Street Address:
*
City:
*
Country:
*
United States
Canada
Dominican Republic
State:
*
Postal Code:
*
Save
Cancel
PO Number:
Notes and Instructions For Shop:
Submit